Posterior Ankle Impingement
Posterior ankle pain in athletes isn’t always “just impingement.”
Often it’s a combined os trigonum + FHL pathology problem.
Takeaway from Arthrex TPC Meeting
Recent patient with persistent posterior ankle pain—worse with push-off and plantarflexion.
Workup:
▪️ Os trigonum on imaging
▪️ Pain with resisted hallux flexion → FHL involvement
▪️ Failed nonoperative management
Surgical Decision: Arthroscopic vs Open
Arthroscopic approach
✔ Less soft tissue disruption
✔ Faster recovery
✔ Direct visualization of posterior ankle
Open approach
✔ Useful for large ossicles or abnormal anatomy
✔ Better for extensive scarring or tenosynovitis
✔ More direct control of the FHL tendon
Critical Point
If you remove the os trigonum and ignore the FHL… you will miss the primary pain generator in some patients.
In this case:
▪️ Posterior ankle arthroscopy
▪️ Os trigonum excision
▪️ FHL tenolysis + release
Let’s Talk Technique (for those doing open)
Curious how others are approaching this:
Medial vs lateral approach?
Medial: more direct access to FHL, but tighter working space
Lateral: more familiar for os trigonum, but indirect access to FHL
Takeaway
Posterior ankle impingement is often a two-structure problem
Bone + tendon
If you’re not evaluating both… you’re not done.